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Analgesic Creams

Behandeling pijn Sudeck dystrofie (CRPS) met ketamine/DMSO

Ketamine 10% cream for Sudeck (CRPS) pain

One of our compounded cream very useful for some Sudeck patients is a topical 10% ketamine cream. Its mechanism of action is most probably linked to peripheral N-methyl-D-aspartate (NMDA) receptors, important for the sensation of severe pain.

Ketamine blocks NMDA and 5HT receptors, Na+ and Ca+ channels, and the edema response associated with inflammation.
In addition to that, ketamine binds to many sites in the central and peripheral nervous systems
including nicotinic, muscarinic, opioid, alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionate (AMPA), kainate, and gamma-aminobutyric acid A (GABA-A) receptors.

Topical ketamine applications have documented success in neuropathic pain patients, in terms of providing some direct analgesia and inhibiting sympathetically maintained pain. [1]

The most important use of our compounded ketamine cream is the reduction of hyperalgesia (an exaggerated pain sensation to a painful stimulus), and the reduction of allodynia (a painful sensation elicited by a nonpainful stimulus). [2]

In literature one can find support for topical ketamine applications for pain management in a variety of pain states: post-surgical neuropathic pain, complex regional pain syndrome as in Sudeck, hernia or lumbar radiculopathic pain, proctodynia pain, diabetic neuropathic pain, oral pains and post-herpetic neuralgia. [3] [4] [5]  [6] [7] [8] [9] [10] [11]

Evidence points out that ketamine cream acts only locally. After applying a 10% ketamine cream compound, no ketamine could be detected in the bloodstream in a trial in 20 patients, and ketamine applied to healthy limbs produced no effect in painful limbs.  [12]

This sorts of compounded topical ketamine formulations have no documented side effects and its efficacy has also been described in CRPS. [13]

Availability of ketamine 10% cream for physicians

Our compounded cream can be used for specific patients in e.g. the Netherlands, Germany and the UK if the physicians order a prescription document at info@neuropathie.nu

Summary of Evidence on Ketamine Analgesia

Level 1 (Evidence obtained from a systematic review (or meta-analysis) of
all the relevant RCTs):

  1. Low-dose perioperative ketamine is opioid sparing, reduces nausea and
  2. vomiting, and has minimal side effects.
  3. Ketamine added to opioid PCA provides no additional analgesic benefit.
  4. Ketamine is most effective as a continuous low-dose infusion for acute pain
  5. management.
  6. Ketamine has “preventive” but not “preemptive” analgesic effects.
  7. Ketamine is a safe and effective sedative/analgesic for painful procedures,
  8. particularly in children.

Level II (Evidence obtained from at least one properly designed RCT)

  1. Ketamine is most effective as an “antihyperalgesic,” “antiallodynic,” or
  2. “tolerance-protective” treatment.
  3. Ketamine is effective as a “rescue analgesic” for acute pain unresponsive to
  4. opioids.
  5. Ketamine reduces acute wound hyperalgesia and allodynia.
  6. Ketamine may reduce the incidence of chronic postsurgical pain following
  7. laparotomy, thoracotomy, and mastectomy.
  8. Ketamine reduces lower-limb ischemic rest pain, peripheral neuropathic pain,
  9. and spinal cord injury pain.
  10. Ketamine improves fibromyalgia symptoms, including tender point count and
  11. aerobic endurance.
  12. Intranasal ketamine reduces breakthrough pain of cancer-related and
  13. noncancer origin.
  14. Ketamine reduces migraine severity in both acute and prophylactic therapy.
  15. Ketamine does not improve analgesia when used alone or in combination with
  16. local anesthetic for peripheral nerve blocks, intra-articular injection, or wound
  17. infiltration.

Level III (Evidence obtained from nonrandomized controlled trials)

  1. Ketamine may be effective for refractory cancer pain in terminal stage disease.
  2. Ketamine may reduce severe chronic phantom limb pain.

Level IV (Evidence obtained from case series)

  1. Ketamine improves analgesia in opioid-tolerant patients.
  2. Intranasal ketamine may relieve migraine aura.
  3. Ketamine may be effective in visceral pain based on human experimental
  4. models and limited case reports.
  5. At least 50% of patients fail to respond to oral ketamine and experience side
  6. effects in the treatment of chronic neuropathic pain.
  7. Long-term ketamine use may be associated with impairment of memory,
  8. attention, and judgment.  

Additional References on topical ketamine cream in CRPS

Keppel Hesselink, JM and DJ Kopsky, Letter to editor, current therapeutic research 2010, 71, 6: 416-417

Trist D. Excitatory amino acid agonists and antagonists: pharmacology and therapeutic applications. Pharm Acta Helv 2000; 74: 221-9.
Sang C. NMDA-receptor antagonists in neuropathic pain: experimental methods to clinical trials. J Pain Symptom Manage. 2000; 19: S21-S25.

Gammaitoni A, Gallagher R, Welz-Bosna M. Topical ketamine gel: possible role in treating neuropathic pain. Pain Med. 2000; 1(1): 97-100.

Crowley K, Flores J, Hughes C, et al. Clinical application of ketamine ointment in the treatment of sympathetically maintained pain. Int J Pharmaceut Compound. 1998; 2: 122-127.

Chronic Pain Coalition Chronic Pain Coalition

Comments

David Baden wrote:

"Zijn Er ook Grotere Tubes met DMSO Creme te verkrijgen?? Nu heb ik 50 gr tube en is zo op. En kost me hoop centen ( word niet vergoed)"
July 15, 2012 at 09:13 PM

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